A key criticism of foreign aid is that donor programs tend to import the commodities needed to support programs, rather than purchasing them locally, which can effectively kill local production industries. This criticism is invoked frequently in the case of food aid and more recently this criticism has been invoked in the case of bed nets for malaria. Most of the nets that have been purchased with donor funds from major global health initiatives have been sourced from producers located outside of the destination country, leaving little opportunity for the development of a local industry to produce these nets. This argument has been discounted by many in the health community that have argued that the lifesaving effects of these nets far outweighs the need to develop a local bed net industry and that health concerns far outweigh economic considerations.

But local production is just part of the story, and I have witnessed another side effects of these strategies, one which could have a more direct effect on health. In addition to production, the effective delivery of bed nets also requires these nets to be imported, distributed, and sold locally. In Ethiopia, prior to massive free bed net distribution programs, there was a local private bed net distribution system. Local businessmen took it upon themselves to import nets into the country and distribute them to retail shops across the country. I’ve seen survey data that suggests that upwards of a quarter of households in some areas purchased bed nets through these private retail distribution channels.

You can probably guess where this is going: Ethiopia won a big project malaria grant and millions of nets were important and distributed free of charge throughout the country, in particular in the areas with high disease burden. The program was perhaps the single largest bed net distribution program ever undertaken anywhere in the world and from what I can tell the nets really did get to those who needed them (what impact they have had on clinical outcomes, is another story which I will leave aside). But, according to people I interviewed, the private distribution channels that existed before this distribution programs suffered major set backs. No one needed to buy a net anymore, so no one did. Importers stopped importing nets, distributors stopped distributing nets, and retailers stopped selling nets. Selling bed nets was no longer good business.

While many more people got a net that perhaps would have ever purchased them in the first place, the problem arises when one considers what will happen over time. Communities were targeted through this grant once and for now there are no plans to return to these communities. In the interim, should a household want to purchase a net, it is now more difficult to do so. The free nets may become less effective over time but it is hard for households to buy replacement nets. The distribution channels that took years to establish have been killed and may never return, in particular if business believes that there is a risk that the public distribution programs will be repeated.

While I don’t think this is necessarily an argument against large scale distribution programs, because I do believe that such programs can achieve higher bed net coverage than leaving it to the free market, I do think it points to how a public-private solution may have avoided some of these problems. Had the donor funds been used to purchase some of the nets from local distributors, using local channels, than the networks might have been saved – even rewarded for their efforts. Saving lives is the priority – no doubt – but sometimes it does not have to be either or – corporate interests are not inconsistent with health interests.

P.S. Since posting this post, Bill Brieger posted a follow-up comment on his website. I thought it was a good follow-up read, so I am linking to it here.

“The world has become fat in just a few decades. The changes in how we eat, drink, and move that have affected billions of people over the last half-century will affect billions more in the coming years. If we don’t do something to stop and reverse these changes, in a few thousand years the only survivors may be those in our species who don’t store fat, who hate sweet foods, and love activity”.

Dire predictions from the new book by Barry Popkin – the imminent nutritionist/economist from the University of North Carolina – entitled “The World is Fat“. Popkin has probably spent more energy – and burned more calories – than anyone over the past few decades studying why the world – even people in developing countries – are getting really, really fat. He chronicles these years of research in his new book.

Popkin’s thesis is that humans were born to eat, it is our biological destiny, and our lifestyles have just made it too easy for us to eat more calories than we need and expend less than we should. So unless large scale population-level policies are adopted, ideally by government, than we are destined to remain fat. He calls for higher taxes on sugar and tighter regulation of the food industry among other initiatives.

I am somewhere in between on this one. I think big population programs have a big role to play, but am not willing to give up on individual behavior change entirely just yet. But I must admit, I am much more convinced after reading his book. I was also somewhat saddened and surprised that countries like Brazil and Mauritania have actually made bigger strides than the US against obesity. Perhaps this is once case where the developing world might take the lead.

I am currently conducting research on transparency and oversight of financial systems in the health sector in Ethiopia. My time here has allowed me to reflect on a number of challenges to health service delivery that this large – and extremely diverse – country is facing. I’ll probably be mulling over most of what I have observed for some time, so expect any overload of info on Ethiopia in the coming weeks – provided I have access to electricity and internet that is!

The Federal Ministry of Health in Ethiopia tends to think big and has recently implemented a number of really large health reforms, including a major expansion in the number of health posts available across the country and the creation of a health extension worker programs to provide basic services in rural communities. The rationale for both of these initiatives is to expand the quantity of basic primary health services available.

Core maternal and chid health indicators in this country are startling – and upsetting. Nationally, only about 5% of births are supervised by trained medical personnel or take place in any sort of medical facility – the lowest I have ever seen. The WHO recommends that about this fraction of births should be receiving a caesarian section – not just the fraction that should be supervised – so the low use of modern delivery services is certainly contributing to the high rates of maternal mortality. It also helps to explain why I have seen so many fistula hospitals scattered across the country.

But I wonder how much of the Ethiopian story can be explained by just the availability of basic services? I suspect that there is a big cultural story that these reforms do not address. But I also think it might have a lot to do with the quality and sophistication of services available. Last week I visited a rural woreda (like a district) about 50 km from a regional capital city in Northwestern Ethiopia The woreda had a population of approximately 350,000 people and while the area had seen substantial expansion in health centers and health extension workers, the woreda still did not have a single health professional qualified to perform a caesarian section. My back of the envelope calculations suggest that roughly 10,000-15,000 births take place in the woreda each year (4% of population), and that about 1000 caesarian sections should be conducted every year (5-8% of births), more than enough to justify a skilled health professional to conduct caesarean sections alone (2 a day, essentially a full workload). But such a professional did not exist.

There is an emerging literature that suggests that poor patients in developing countries demand more than just basic services – it suggests that they are intelligent consumers willing to pay more for higher quality services. A recent Health Policy and Planning article by Margaret Kruk and co-authors makes this point for delivery services in Tanzania – a substantial share of women bypassed the primary services available to them in their communities for services that they perceive to be of higher quality at a substantially higher price. It may very well be the case that Ethiopian women don’t value the types of services that are available to them and that even large scale expansions of basic health services will never satisfy their needs.

It is unfortunate that trade offs between quantity and quality must be made – but usually that is the reality in a resource constrained environment like Ethiopia. Donors have shown that ensuring both is possible for HIV/AIDS treatment programs – the HIV wing is always the fanciest place at every health center – but it is too bad that there is not more emphasis on quality in other aspects of the health sector. Until such concerns are address, I fear that little progress will be made.

Whenever I am in Africa, I give a lot of through to the topic of road traffic injuries. I have now been in Ethiopia for just over a week and half and have personally seen evidence of 3 different road traffic accidents: a likely fatal flip of an overloaded van full of passengers and materials on the road between Bahar Dar and Gondar, a relatively minor accident between a Bajaj (Indian made 3-wheel rickshaw taxis) with a 4-by-4 in Bahar Dar, and a pile up of cars on a busy street in Addis. It is no wonder that many of the inpatient patients I visited with last week at a local referral hospital were there to recover from road traffic injuries.

Last evening I took the free airport shuttle from my hotel in Bahar Dar to catch my flight back to Addis. Our driver, a elderly old man, drove most of the trip at relatively high speed down the dark highway right down the middle of the road. Normally this is a pretty good strategy as there are frequently goats or cattle along one side of the road. However, whenever we approached a car coming in the other direction, for whatever reason, he actually swerved more onto the wrong side of the road, forcing the other car to slow down dramatically to ensure safe passage to our left. I could see us all going through the mental calculation that James Habyarimana and Billy Jack model in their paper Heckle and Chide – who of us was going to speak up first and ask the driver to improve his behavior? Luckily a guy in the front seat’s benefits outweighed his costs and he spent the rest of the drive heckling our driver to stay on the right.

I therefore thought this chart from the Economist on legal blood alcohol limits was interesting. Over 170 countries in the world have imposed legal alcohol limits. The WHO recommends a level of no more than 0.05 g/dl, meaning that the US and Canada, and countries in the UK actually have more lenient laws than recommended by the WHO. Africa, however, is scattered with some countries with strict WHO standards, others with standards equivalent to those in the US or the UK, and some with no limits at all. Ethiopia, sadly, is one of those with no legal limit. Of course having a law, and enforcing a law is a different matter, but at least it is a start. I wonder to what extent these rules have any impact at reducing accidents in developing countries?

I pride myself about knowing a thing or two about diseases most people have never heard about before. It makes for wonderful dinner conversation to discuss the horrible worm diseases (or when I am trying to really impress: helminthic diseases) that cause a multitude of disfiguring or disabling conditions that afflict the poorest of the poor in developing countries. Therefore it was a bit embarrassing when my lunchtime conversation with Owen Barder, a development economist and blogger, led us to discuss podoconiosis – a disease that I had never heard of before – yet it afflicts millions of people in Ethiopia, other parts of Africa, Central America, and even India.

As it turns out, podoconiosis is actually a form of a disease I do know something about – lymphatic filariasis – but unlike the *vastly* more popular version of the disease that is caused by worm, podoconiosis is a non-infectious version that is believed to be caused by frequent exposure to the red clay soils that are common in many parts, in particular the mountainous parts, of Africa. It mainly afflicts poor farmers in remote mountainous areas that are too poor to regularly wear shoes and socks when tending to their fields. It leads to essentially the same symptoms as the helminthic version of the disease: extreme disfigurement, loss productivity, and social exclusion of its victims.

Like regular LF, podoconiosis suffers benefit from regular washing of the affected area, mostly to remove the irritants and prevent bacterial and fungal infections of the area but presumably does not benefit from the distribution of anti-helminthic drugs such as albendazole, ivermectin, or diethylcarbamazine. It is a neglected, neglected tropical disease. But prevention is relatively straightforward: the regular use of sturdy shoes and socks. I was suprised to learn that there is actually a company – Toms Shoes – that has already committed to donating shoes to people in affected areas.

Sometimes, I am not very intelligent. A few years back I went on a trip to China with my husband. On our first dinner in Beijing, I thought to myself “Did I turn off the Iron?”. So for the rest of the trip I was haunted by the fear that I had left it on. When I turned the corner onto my street upon my return I was happy to see my house was not in ashes. However, I actually had left the iron on and although it must have gone on and off, it was definitely hot when I got back. I could have benefitted from one of these:

In fact, I thought a few of these vintage health and safely posters being distributed by Vintagraph were quite cute and makes me nostalgic about the post-germ theory pre-antibiotic years.

That is exactly what happened with the CIPRA HT 001 clinical trial on ART initiation conducted by NIAID supported researchers in Haiti. About 800 patients presenting with clinical HIV disease and CD4 counts ranging between 200 and 350 were randomized to receive ART treatment nearly immediately, or once they reached a CD4 cell count below 200 (current standard practice in developing countries). After approximately 3 years, there was a nearly 4 fold difference in mortality rates among the groups (23 vs. 6 deaths) and also significantly lower rates of TB incidence. When differences this striking emerge from clinical trials, it is generally considered unethical to continue them and thus they are stopped and everyone is given the superior treatment.

Evidence has been accumulating for years about the benefits of early treatment in terms of decreased mortality, but because none of the previous studies were randomized trials, some skepticism remained. Unobserved severity of patients by themselves and their providers always weakened the findings of such studies, despite the fact that the differences between the groups were relatively large.

I’ve blogged about the implications of early treatment before (here and here). Current treatment guidelines are based on a belief that drugs should be rationed to the sickest patients first, but this evidence suggests that treating patients earlier may do more to save lives. It means is that for the same resource envelope fewer people will receive treatment if earlier treatment protocols are adopted (since they live longer) or that more resources will be needed to treat the same number of people (note this is not saying that one approach is more cost-effective than another, this is a different argument). What I find most remarkable about this study is that they were comparing relatively sick patients to slightly sicker patients (earlier studies looked at even higher CD4 cut offs than here) and still finding these differences. What if they had started with CD4 initiation levels that are sometimes used in developed countries?

It seems some serious debating, and potentially revising, of treatment guidelines is on its way.

It is a well known phenomenon that more male children survive childhood than female children in many developing countries. There have been many theories put forward to explain why there are so many “missing girls” in parts of Asia, which have ranged from structural neglect (Sen), hepatitis B vaccination (Oster), and selective use of abortion technologies (my friend Avi Ebenstein‘s theory). Without getting into some of the messiness of the arguments in this literature, I’ll just say that I think all of these factors could be important.

A new theory, however, has entered into the mix. It is reasonably well known fact that nursing mothers are less fertile (I knew this, and lets just say I know a whole lot less about fertility than most women my age). Breastfeeding inhibits ovulation via hormonal regulation as well as via calorie restriction (in particular in low calorie consumption countries). While not a perfect contraceptive, it does appear to delay fertility for at least a few months. Whether women in developing countries know this or not, is an important question for the validity of this theory, but my sense is that there are certain indicators available to women to evaluate fertility and it would be reasonable that women would notice the negative association between nursing and the return of these indicators.

Seema Jayachandran and Ilyana Kuziemko have just released an NBER working paper that argues that early weaning of female children might also account for some of the missing girls. The argument goes like this: breastfeeding is a really good thing to improve survival of children (this we know, don’t need to convince me), women know that they are less fertile while breastfeeding, so when they give birth to a female child but have a preference for male children they will wean girls earlier than they would wean boys to speed up when they can try for another child. As a result, female children are more prone to illnesses and will die at a higher rate.

The authors mine fertility survey data from India and do, in fact, find that female children are weaned sooner than boys. They also find that subsequent children who already have an older brother are weaned longer (less need to try for another child) and that higher birth order in general is associated with longer breastfeeding (potentially because women are relying upon breastfeeding to reduce their fertility). They also argue that women with a few children are the most likely to take advantage of this technology, as the stakes are higher at this point. They test these hypotheses, which are all supported by their data.

I like this theory, and I also really like that the authors have thought through some of the potential policy implications of these findings. They speculate that as modern contraceptive technologies become more available, than women will rely less upon breastfeeding to control their fertility and may breastfeed all children less. They argue that the roll out of contraceptives should be accompanied by information campaigns to stress the health benefits to children of breastfeeding (I dont know if this is currently done or not, but agree that this could be a potential problem that should be addressed).

I am leaving this evening for 3 weeks in Ethiopia, where I am working on a really interesting health sector project for the World Bank. Electricity and internet may not be so readily available, so please do not be surprised if you only hear from me periodically. But travel tips, if you have them, would be most appreciated.

I love maternal mortality. By that, of course, what I mean that I think it is a fascinating research question, one which has received far too little attention from researchers. Maternal mortality was common in both developed and developing countries as late the mid-1900s, but maternal mortality began to decline dramatically in most developed countries around the 1930s. Today maternal mortality is one of the most unjust and unequal measures of population health between the developed and developing world. Our best guess is that 99% of maternal deaths occur in developing countries.

I am reading a great book right now called “Death in Childbirth” by Irvine Loudon. Published in 1992, it is an international study of maternal mortality in the developed world from 1800-1950. I am a big fan of history, and think that understanding the declines in the developed world is key to developing more effective policies to reduce maternal mortality. Or at least, it is good to learn from our mistakes every now and again.

Eclampsia, known then as toxaemia, was among the leading causes of maternal death during the early twentieth century, then as now, the exact causes of eclampsia are largely unknown. I loved this quote regarding eclampsia:

“If the cause of a disease is unknown, renaming it not only reflects new theories, but produces an illusion of progress.”

Eclampsia is characterized by a period of increased blood pressure, known as pre-eclampsia, which may or may not lead to convulsions. It is relatively common, even today. At the time, blood pressure monitoring was not common and the disease was thought to be some sort of a toxic reaction to the placenta, hence the name. It eventually became known that high blood pressure was a predictor of this condition, so it was recommended that the blood pressure of women be monitored during pregnancy to screen for those who may develop eclampsia. From this recommendation, antenatal care was born.

Prior to this recommendation, antenatal care was rare. The use of antenatal care only became widespread during the period following the first world world, essentially during the 1920s. Antenatal care was instituted specifically to reduce maternal mortality from eclampsia, the other two major causes of maternal mortality at the time were puerperal sepsis and hemorrhage, both of which were mainly influenced by the care receiving during the delivery process. There was little evidence, however, that providing antenatal care did much to reduce maternal mortality, but as today, there was a feeling that it was necessary and providers were shunned if they did not provide such services.

Treatment of eclampsia, on the other hand, was a different ball game. Dozens of different treatments have been tried over the decades, from bleeding, to aspirin, to the Stronganoff treatment, which was fashionable throughout much of the early twentith century. It consisted of the following:

“The main features of the Stroganoff regime were very heavy sedation combined with magnesium sulphate, and the isolation of the patient in a darkened and totally quiet room where she was attended by staff tiptoeing in stockinged feet and peering in the dark. It was based on the theory that stimuli, auditory and visual, were the triggers of eclampsia. The method gained credence because it was so dramatic.”

Treatment today usually entails trying to lower the blood pressure of the mother, usually through the administration of a drug, such as magnesium sulphate, and early induction of labor. Eclampsia is harmful to both the mother and the child, and seems to resolve itself once the placenta is removed, so early labor is often induced, sometimes through caesarean section. Magnesium sulphate, one of the best drugs available to treat pre-eclampsia, is cheap and generally available. I have seen some research from Mexico recently that showed that it is rarely used appropriately in that setting.

If the screening for eclampsia is one of the main reasons for ensuring antenatal care, I would like to see more use of indicators to monitor how effective antenatal care is in addressing this issue. The DHS regularly collects data on whether the blood pressure of the mother was monitored, but I think it is whether pressure and urine were ever monitored, and reporting instead focuses on the number and timing of visits, and not whether these visits are high quality visits.